Forte Group Sri Lanka and Global Hospitals India make ‘Awake Craniotomy’ a reality
Tuesday, 22 April 2014 00:06
Global Hospitals Group, one of the fast growing, multi-super specialty tertiary care hospital chains in India, with advanced paediatric liver transplantation programs and paediatric super speciality services for liver/HPB, cardiac sciences and gastroenterology as well as neurosciences, has once again proven to be a trailblazer by successfully performing brain surgery using the ‘Awake Craniotomy’ method.
In Sri Lanka was Dr. K. Sridhar, Adjunct Professor, Tamil Nadu Dr. MGR Medical University, and Director Institute of Neurosciences and Spinal Disorders and Chief Brain and Spine Surgeon of Global Hospital and Health City – Chennai India, who together with Chairman of the Forte Group (local representatives of Global Hospitals) M.F.A. Riyas, elaborated on this technique, the main feature of which is the fact that the patient is kept awake and is able to obey simple commands and talk during the brain surgery.
Cooperation and coordination
“Critical to this technique is the fact that the brain itself does not feel any pain sensation. It is the scalp, the bone and the coverings of the brain that have pain sensation. In order to perform ‘Awake Craniotomy,’ it is essential to have a cooperative and well-informed patient as well as coordinated team work between the anaesthesiologists and the surgeons. Patients need to be counselled before surgery and assessed whether they will be cooperative, as they would need to lie still and not move their head for the duration of the procedure,” said Dr. Sridhar.
He said that patients have to be made to understand that they would be woken up and kept awake during their surgery. He stressed the fact that the doctor should explain to the patient that they would hear a lot of different sounds from the various equipment in the operating theatre, which in normal circumstances could severely raise anxiety levels. “The patient would also need to understand what the anaesthesiologist and the surgeon would be asking of them,” he said.
One of the major aims of brain surgery is to ensure that the patient does not suffer any new disabilities after the procedure. The most effective method of treatment of a brain tumour is to remove it completely. The surgeon therefore has to be aggressive and remove the tumour completely on the one hand, while at the same time avoiding giving the patient a disability that would affect the quality of life.
Advances in technology and the availability of new anaesthetic drugs have made neurosurgical operations on the brain safe, with the complication rate down to less than 3% in most cases. However, when the tumour or pathology lies in a part of the brain that is responsible for speech or for movement of either the hands or legs, it is a challenge.
“To help overcome this challenge, technological advances in radiology have come to our aid with special MRI techniques. Functional MRI (or fMRI) shows the exact relationship between the tumour and important ‘functional’ areas of the brain like the speech area and motor areas. Diffusion Tensor Imaging (DTI), also called tractography, helps the surgeon visualise the nerve fibres and connections between different parts of the brain and their displacement by the tumour. However, these images give surgeons only static information. What is needed is ‘dynamic’ and ‘online’ information as the surgeon operates, to tell him or her where the critical areas of the brain are and more importantly when to stop operating.
“During the surgical procedure itself, providing the right balance of analgesia (pain relief) and sedation is the greatest challenge for the anaesthesiologists,” said Dr. Sridhar, adding that patients are given different levels of sedation at different stages of the operation to keep them comfortable.
“The anaesthesiologist starts the procedure by anesthetising the entire scalp by giving a ‘scalp block,’ rendering the skin of the head completely numb and pain free. At the same time different monitoring devices are connected to the patient to ensure safe surgery. As the depth of sedation of the patient is crucial in this surgery, the patient’s brain activity needs to be monitored. This can be done by various methods, one of which is entropy.”
At the start of the surgery, the patient is made to sleep with a higher dose of sedative drugs. This allows the surgeons to make the opening in the scalp and the skull bone. Once this is done and the surgeons are ready to start the work on the brain itself, the sedation dosage is titrated to awaken the patient and keep him or her awake during the next phase of the surgery.
Brain surgery is performed using an operating microscope that allows the surgeon to visualise the normal and abnormal tissues with clarity, making surgery precise to the millimetre. As the surgery proceeds, the surgeon and the anaesthesiologist talk to the patient and assess the movement and power of the hand and leg. The critical part of the surgery is when the surgeon is removing the margins or peripheral part of the tumour.
“This is when there is a maximal chance of damage to the normal functioning brain. During this time if there is any decrease in function of the hand or leg or if any difficulty in speech is noted, the surgeon immediately stops the tumour removal in that area, knowing that it is a danger zone. A change in the surgical technique may also be used to change the outcome. In this way tumours in critical areas of the brain can be removed without giving the patient a major neurological disability.”
Once the tumour removal is done, the patient’s sedation is increased and he or she is put back to sleep, so that the wound can be closed.
Post-surgery the patient is awake almost immediately and is shifted to an intensive care ward completely awake and talking. The patient stays in the Neurosurgical Intensive Care ward for the night and is shifted the next morning to the ward.
Dr. Sridhar said that oral fluids are started the evening of the surgery itself and the patient could get out of bed the next morning. After three to four days in the ward to ensure that the patient is comfortable, he or she can be discharged. The patients are asked to come back for a review a week later for removal of stitches and to guide them regarding further medications and management.
The ‘Awake Craniotomy’ technique is used specifically for patients with lesions and tumours in and around ‘eloquent’ areas of the brain that control speech and limb movements. It allows for maximal tumour removal in areas of the brain that were till recently thought to be regions where surgery should not be done. It requires great skill and expertise on the part of the anaesthesiology and the surgical teams, using technology to perform difficult and challenging surgical procedures and giving the patient a good quality of life.
Global Hospitals Group is a multi-super specialty tertiary care hospital chain with India’s largest multi-organ transplant centre for liver, heart, lung and kidney transplantations, supported by world class infrastructure, state-of-the-art technology and a strong commitment to deliver exceptional patient care.